The surgical management of recurrent tracheal schwannoma.

A case of a primary tracheal schwannoma refractory to endoscopic treatment in a 54-year-old male is reported. Previous treatment was by endoscopic laser debulking. Computed tomography (CT) 2 months later demonstrated a recurrent tumour involving the anterior tracheal wall with intraluminal tracheal extension. Treatment was successful by limited tracheal resection with primary anastomosis performed 2 weeks following the scan. The histology confirmed a benign neurogenic tumour derived from Schwann cells and clear margins.

Voice outcomes for early laryngeal cancer.

PURPOSE OF REVIEW: Treatment options for early laryngeal cancer are well established with good local control and 5-year survival. The commonest treatments are radiotherapy or transoral laser microsurgery (TLM). There are advantages and disadvantages of the different modalities, but debate continues regarding the voice outcomes posttreatment. This review will focus on early glottic carcinoma and voice outcomes following the different treatments. RECENT FINDINGS: TLM and radiotherapy are both likely to affect voice quality, but the extent of voice change depends on different factors. These factors can be divided into patient, tumour and treatment factors. Recent meta-analyses data show similar voice outcomes for either modality in the treatment of early glottic carcinoma. However, larger tumours and those involving the anterior commissure are associated with worse voice outcomes. SUMMARY: There are various considerations for the patient and clinician before deciding on the preferred treatment for early glottic carcinoma. Although both TLM and radiotherapy will affect voice outcomes, the recent meta-analyses show similar voice outcomes for either modality in the treatment of early glottic carcinoma. There are numerous variables in the published studies hindering direct comparisons. These include heterogeneous patient groups, different treatment standardization and methods of voice analysis.

Voice and swallowing outcomes for adults undergoing reconstructive surgery for laryngotracheal stenosis.

PURPOSE OF REVIEW: Adult laryngotracheal stenosis is a rare, multifactorial condition which carries a significant physical and psychosocial burden. Surgical approaches have developed in recent years, however, voice and swallowing function can be affected prior to treatment, in the immediate postoperative phase, and as an ongoing consequence of the condition and surgical intervention. In this study we discuss: the nature of the problem; surgical interventions to address airway disorders; optimal patterns of care to maximize voice and swallowing outcomes. RECENT FINDINGS: Studies in this field are limited and focused on surgical outcomes and airway status with voice and swallowing a secondary consideration. Retrospective studies of swallowing have focused on factors such as the duration of dysphagia symptoms following airway surgery and made comparisons between type of surgery, use of stent, and length of swallowing problems. The literature suggests that patients are likely to return to their preoperative diet. There has been a focus on voice outcomes following cricotracheal resection which results in a postoperative decrease in the fundamental frequency. However, study comparisons are limited by the use of inconsistent outcome measures (for both voice and swallowing) which are often not validated, with heterogeneous groups and varying surgical techniques. SUMMARY: The limited literature suggests that swallowing function is more likely to recover to presurgical status than voice function. Further prospective studies incorporating consistent instrumental, clinician, and patient-reported outcome measurement are required to understand the nature and extent of dysphagia and dysphonia resulting from this condition and its treatment.

Opsoclonus-myoclonus syndrome associated with a nasopharyngeal tumor in an adult: a case report.

INTRODUCTION: Opsoclonus-myoclonus syndrome is a rare autoimmune syndrome usually seen in children and very rarely in adults. It typically presents with a triad of opsoclonus, myoclonus and ataxia, and is most often associated with a tumor or after an infection or vaccination. Around half of all adult cases are paraneoplastic in origin, and isolated case reports include associations with lung, breast and ovarian cancers. To the best of our knowledge, this is the first-ever reported case of paraneoplastic opsoclonus-myoclonus syndrome occurring in association with a nasopharyngeal carcinoma. CASE PRESENTATION: A 50-year-old British Caucasian woman presented with left-sided otalgia and subjective hearing loss. Over the coming weeks she developed subacute confusion and dizziness, leading to recurrent falls. Her clinical examination revealed opsoclonus, myoclonus and signs of cerebellar dysfunction. Subsequent magnetic resonance imaging revealed a left-sided nasopharyngeal carcinoma, which was confirmed on biopsy. A tapering dose of steroids and a five-day course of intravenous immunoglobulins, followed by a combination of chemo-radiotherapy for the nasopharyngeal carcinoma, led to a significant clinical improvement. At six months follow-up she had no signs of focal neurological deficit, apart from the inability to tandem walk. We believe that the typical clinical features, presence of a tumor and response to treatment support a paraneoplastic aetiology. CONCLUSIONS: We show that a nasopharyngeal carcinoma can be associated with adult onset opsoclonus-myoclonus syndrome. Both neurologists and otorhinolaryngologists must be aware of such a presentation. Prognosis of the syndrome depends on early and adequate management of the tumor, therefore prompt identification of the syndrome and the underlying tumor is essential.

Linear accelerator radiosurgery for vestibular schwannomas: Results of medium-term follow-up.

BACKGROUND: To examine tumour control, via volume changes, and the complications of linear accelerator (LINAC)-based stereotactic radiosurgery (SRS) treatment of vestibular schwannomas (VSs) on medium-term follow-up. METHODS: Between September 2003 and November 2009 fifty consecutive patients with VSs treated with SRS using a marginal dose of 12.5 Gy utilizing a LINAC equipped with a micro-multileaf collimator were identified. Evaluation included serial magnetic resonance imaging (MRI), and neurological and hearing examinations. RESULTS: The median tumour volume at treatment was 2.4 (range: 0.24-10.59) cm3. The intracranial diameter of the tumours ranged between 7.7 and 28.7 (median: 15.8) mm. Follow-up MRI was available for analysis on 49 patients. The median radiological follow-up period was 5.8 (range: 1.4-9.2) years. The median tumour volume at last follow-up was 1.1 (range: 0.03-5.3) cm3. VS decreased in size in 45 (90%) patients, with a median reduction in tumour volume of 1.46 (range: 0.06-9.29) cm3 or a median tumour size reduction of 59% of the baseline (range: 6-90%) in these patients. VS remained stable in 2 patients and increased in size in 2 patients. Only 1 patient (2%) required additional intervention (surgery). 15 patients had useful hearing pre-treatment; 10 post-treatment pure-tone audiograms of these patients were available. 5 (50%) patients still had useful hearing post treatment. Non-auditory adverse radiation effects included new (House-Brackmann grade II) or worsened facial nerve palsy (House-Brackmann grade II to grade V) in 2 (4%) patients and trigeminal sensory disturbance in 2 (4%) patients. CONCLUSIONS: At medium term, the vast majority of VSs treated with LINAC-based SRS exhibit tumour shrinkage. The slightly higher rate of facial nerve palsy compared with Gamma Knife surgery (GKS) results may be related to the learning curve. Other complications were similar to reported GKS results for VSs of comparable sizes.

Laser safety in head and neck cancer surgery.

The use of trans-oral laser techniques for the resection of head and neck carcinomas has increased exponentially over the last four decades. Inadvertent laser damage to the patient or operating theatre staff is an acknowledged risk. However, no data exist to verify the safety margin of commonly employed precautions. The aims of this study was to assess the safety margins of protective strategies commonly adopted when using CO(2) lasers to resect tumours of the head and neck. A Sigmacon Acupulse Lumenis CO(2) laser was evaluated. The beam was focused to 2 mm diameter at 402 mm focal length. Gauze swabs, neurosurgical patties, surgical gloves, paper drapes and conventional endotracheal (ET) tubes were tested against the following laser variables: power, beam characteristics and angle of beam incidence (90 & 45°). Laser penetration time through the material under test was recorded in seconds (s). All the materials where tested dry and some, when appropriate, were tested wet. The mean of three recordings was calculated. The results demonstrated dry gauze swabs, neurosurgical patties and paper drapes provided 0 s protection at 2 W (lowest power). However, when wet, the laser failed to penetrate the swabs and neurosurgical patties, even after 180 s of continuous application. Gloves (single or double layer), and ET cuffs were penetrated in less than 1 s at 2 W. Time to penetrate a size 6.0 ET tube at 2 W continuous setting increased from <1 s at 90° to 42 s at 45°. These data are essential for anyone using CO(2) lasers for the resection of head and neck tumours. The importance of keeping laser consumables wet throughout the procedure is highlighted. The angle at which the laser hits the ET tube may impart some protection against airway fire but the data support the need to cover the ET tube with damp swabs or neuropatties when possible.